Fabrice Brunet, MDM.I.C.U-E.D Cochin, Paris

C.C.D. St Michael’s, Toronto

Teamwork Training in Critical Care

Training in Critical Care• Education system in nursing and medicine give

clinical skills to individuals

• Superb individual skills do not guarantee effective team performance in care delivery

• Effective teamwork does not arise spontaneously and needs behavior changes

• Teaching of teamwork as integral in critical care is uncommon

Teamwork Training is:

• A novel education model derived from aviation organisations

• Designed to train professionals

• Behavior-based teamwork course

• Using Problem-based learning

• Multidisciplinary groups

• Formal training program

Teamwork training is not

• An individual education system

• Focused on clinical skills

• Designed to teach students

• A transdisciplinary training

Teamwork training: Rationale

• C.C.Ds are at risk environments

• Patients conditions are complex

• Technologies are always evolving

• Care needs multidisciplinary interactions

• Consequences of errors are severe

• Burn-out Syndrome is common

Teamwork training: Goals

• Enhance department performance

• Improve Quality of Patient Care

• Reduce errors and litigation risks

• Improve patients/relatives comfort

• Develop multidisciplinary approach

• Increase staff satisfaction and as a result retention and recruitment of staff

Teamwork system: a standardized program

• Teaching teamwork behavior and skills

• Designed for a « core team »

• Group animation concept

• Multidisciplinary teaching approach

• Interactive teaching method

• Topics selected on team needs

Organisation of seminars• Same team during the whole duration

• A coordinator following the team

• Multidisciplinary teachers

• Location: outside/inside the I.C.U

• Three kind of topics: medical, ethics, organisation

• Methods of training: lectures, simulation, clinical situation

Methods of training• Expert lecture: state-of-the art adapted for a

multidisciplinary audience: Evidence-based

• Simulation: Workshop allowing to adjust

recommendations to real practice and to define

local protocols: Experience-based

• Clinical situation: confrontation with current

practice: Real life

Factors of success

• Involvement of the Head of the C.C.D

• Steering committee

• Motivation of the team

• Training of the teachers

• Choice of appropriate topics

• Financial support by the institution

• Frequent reports of results

Evaluation

• Evaluation of training itself– Questionnaire of satisfaction

– Assessment of team performance

• Evaluation of its results on practice– Implementation of new advances

– Quality indicators

– Analysis of adverse events

Performance assessment

• Team and not individual performance

• Measurement of performance indicators during repeated simulations S.O.C.E.

• Assessment of team performance in clinical situations and novel techniques

• Decrease of adverse events

• Quality indicators: Audits and M.I.T

Protocol of bedside surgery in ARDS

• Preparation before operation

• Patient stabilization and information

• Equipment verification

• Team organization

• Surgical procedure

• Incision and Dissection of pleural adhesion

• Insertion of chest tube

• Pulmonary, pleural and cutaneous repair

• Postoperative detection of surgical complicationsPostoperative detection of surgical complications

• Surgical procedure – Dissection of pleural adhesions 11 pts– Insertion of chest tube 3.4 ± 1.2 /BT (1-

7)– Pulmonary repair 11 pts– Pulmonary biopsy 3 pts

Bedside surgery: Results 1.

• Re-operationRe-operation– Postoperative bleedingPostoperative bleeding 4 pts4 pts– Persisting air leak / bleedingPersisting air leak / bleeding 8 pts8 pts

• Postoperative complicationsPostoperative complications– HemothoraxHemothorax 7 pts7 pts– Hemodynamic instabilityHemodynamic instability 2 pts2 pts– Septic shockSeptic shock 3 pts3 pts

• 66 bedside thoracotomies in 33 patients– Elective / emergency 45 / 21

• Indication – Pneumothorax / BPF 39 (59 %)– Hemothorax 27 (41 %)

• Ventilatory support during thoracotomy– CMV 16 BT– ECCO2R 36 BT– HFO 12 BT– Partial liquid ventilation 2 BT

• Intervention outcome – Resolution of PTX /HTX 41 (62 %)– Failure 25 (38 %)– Survival 15 (46.8 %)

Bedside surgery: Results 2.

Quality of care markers• Previously identified indicators

– Time between admission and treatment

– Patients or relatives satisfaction

– Global cost of a care for given diseases

• Followed in a C.Q.I approach– Evidence based protocols

– Medical Information Technology

– Case and disease management

Quality

Research

Education

Communication

Care

Continuous Quality Improvement

Experience- based

Protocols

Corrections

Continuing Measurementsof indicators

Dysfunctioning

Evidence-based

Reduction of errors

• Number of adverse events

• Spontaneous report of human errors

• Design of multidisciplinary protocols

• Analysis of critical situation

• Benchmarking with other C.C.Ds

Teamwork in restructuring E.Ds

• Tested in Cochin ED with teamwork training– 4 seminars of 1 week each – Repeated for 4 teams (140 h / team / yr)– Evaluated by C.Q.I with M.I.T

• Same program used in 3 other E.Ds– 1 pediatrician with adapted topics to children– 2 adults with adapted topics to environment

Teamwork in E.Ds: results• Successful introduction of a new organisation

– Triage, Observation units– Electronic patient chart

• Increased department and team performance– Reducing waiting time for each step of the circuit– Designing Fast tracks for severely patients

• Improving patient and team satisfaction– Decrease in patient complaints– Increased attractiveness of the E.Ds

Perspectives

• Develop multicenter international studies on teamwork training sytems in C.C.Ds

• Implement teamwork training early in the course of medical and nursing education

• Design new systems of training to improve transdisciplinary teams performance

A few references

• Brennan TA et al: The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:370-376.

• Brennan TA et al: Hospital characteristics associated with adverse

events and substandard care. JAMA 1991;264:3265-3269.• Classen DC et al: Computerized surveillance of adverse drug events in

hospital patients. JAMA 1991;266:2847-2851.• Helmreich R: Managing human error in aviation. Sci Am 1997;5:62-67.• Leape L. Error in medicine. JAMA 1994;272:1851-1857.• Phillips K: The Power of Health Care Teams: Strategies for Success.

Oakbrook, IL: Joint Commission on Accreditation of Health Care Organizations, 1997.

• Risser DTet al: The potential for improved teamwork to reduce errors in the emergency department. Ann Emerg Med 1999;34:373-383.